2011 REVIEW OF PHYSICIAN RECRUITING INCENTIVES. An OvervIew Of THe SAlArIeS, BOnuSeS, AnD OTHer IncenTIveS customarily used TO recruit PHySIcIAnS

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1 2011 REVIEW OF PHYSICIAN RECRUITING INCENTIVES An OvervIew Of THe SAlArIeS, BOnuSeS, AnD OTHer IncenTIveS customarily used TO recruit PHySIcIAnS 2011 Merritt Hawkins 5001 Statesman Drive, Irving, Texas (800) MerrittHawkins.com

2 2011 REVIEW OF PHYSICIAN RECRUITING INCENTIVES An Overview of the Salaries, Bonuses, and Other Incentives Customarily Used to Recruit Physicians IN THIS REPORT Key Findings MERRITT HAWKINS 2011 REVIEW OF PHYSICIAN RECRUITING INCENTIVES: RECRUITING ASSIGNMENT CHARACTERISTICS AND METRICS TRENDS AND OBSERVATIONS WHO IS IN DEMAND? WHERE ARE THEY RECRUITING? INTO WHICH SETTINGS? WHAT ARE THEY OFFERING? SUMMARY Merritt Hawkins Additional Surveys Page 4 Pages 5-16 Page 16 Pages Pages Page 23 Page 26 Page 27 For additional information about this survey contact: Phil Miller (800) Statesman Drive, Irving, Texas MerrittHawkins.com 2

3 OVERVIEW Merritt Hawkins is a national healthcare search and consulting firm specializing in the recruitment of physicians in all medical specialties as well as select allied health professionals. Established in 1987, Merritt Hawkins is a company of AMN Healthcare (NYSE: AHS) the nation s largest healthcare staffing organization and a leading nationwide provider in all four of its business lines: travel nurse staffing, locum tenens staffing, physician permanent placement services and allied healthcare professional staffing. This report marks Merritt Hawkins 18th annual review of the search and consulting assignments the firm conducts on behalf of its clients. The 2011 Review is based on the 2,667 permanent physician and advanced allied professional search assignments that Merritt Hawkins/AMN Healthcare s physician staffing companies were engaged to conduct during the 12-month period from April 1, 2010, to March 31, The intent of the Review is to quantify financial and other incentives offered by our clients to physician candidates during the course of recruitment. The range of incentives detailed in the Review may be used as a benchmark for evaluating which recruitment incentives are customary and competitive in today s physician job market. In addition, the Review is based on a national sample of search assignments and provides an indication of which medical specialties are currently in the greatest demand and the types of medical settings into which physicians are being recruited. Following are several key findings of the Review. 3

4 Key Findings Merritt Hawkins 2011 Review of Physician Recruiting Incentives reveals a number of trends within the physician recruiting market, including: Demand for physicians remains strongest in primary care. For the sixth consecutive year, family practice and general internal medicine were Merritt Hawkins top two most requested physician search assignments. Hospitals continue to employ physicians in ever greater numbers. Fifty six percent of Merritt Hawkins physician search assignments in featured hospital employment of the physician, up from 51 percent the previous year and up from 23 percent in 2005/06. Physicians are seeking the stability of employment, while hospitals are seeking to align with physicians in response to healthcare reform, which is promoting the use of Accountable Care Organizations (ACOs), bundled payments and other physicianaligned and integrated delivery mechanisms. In a sign of increased physician employment, salaries have almost entirely replaced income guarantees (traditionally used to recruit private practice physicians) as a compensation model. Only nine percent of physician search assignments Merritt Hawkins conducted in featured income guarantees, down from 21 percent in and down from 41 percent 2003/2004. The majority of search assignments (74 percent) Merritt Hawkins conducted in featured a salary with production bonus. Most such bonuses (52 percent) are based on a Relative Value Units (RVU) formula. Though health reform encourages the use of quality or cost based compensation metrics, few search assignments Merritt Hawkins conducted in featured such metrics. Volume/production remains the standard. Patient aging, a stagnant economy, continued unemployment, two wars, and a limited supply of practitioners continues to drive demand for psychiatrists. Psychiatry was Merritt Hawkins 4th most requested search assignment in, up from 10th four years ago. Reimbursement cuts and declines in elective procedures have significantly reduced volume of search assignments for certain specialists. Radiologists, cardiologists and anesthesiologists, all among Merritt Hawkins most requested search assignments four to five years ago, were the firm s 17th, 18th, and 19th most requested assignments in. Signing bonuses, relocation and continuing medical education allowances remain standard in most physician recruitment incentives packages, rather than the occasional carrot they were in years past. Housing allowances are a new form of recruiting incentive that some facilities are offering to assist physicians. Due to the volatile real estate market, some physician candidates are unable to relocate without such assistance, which was offered in six percent of the recruiting assignments Merritt Hawkins conducted in, up from less than one percent in previous years. Demand for physicians is not confined to traditionally underserved rural areas. A plurality of search assignments Merritt Hawkins conducted in (44 percent) took place in communities of 100,000 or more. Only 22 percent of assignments took place in communities of 25,000 or less. 4 Following is a breakout of the characteristics and metrics of Merritt Hawkins 2010/2011 physician recruiting assignments.

5 MERRITT HAWKINS 2011 REVIEW OF PHYSICIAN RECRUITING INCENTIVES: RECRUITING ASSIGNMENT CHARACTERISTICS AND METRICS All of the following numbers are rounded to the nearest full digit. 1 Medical Settings of Physician Search Assignments Hospital Group Solo *Partnership Association 1,495 (56%) 505 (19%) 54 (2%) 344 (13%) 82 (3%) 1,430 (51%) 674 (24%) 114 (4%) 338 (12%) 58 (2%) 1,481 (45%) 953 (29%) 362 (11%) 428 (13%) 4 (>1%) 1,416 (45%) 1,170 (37%) 159 (5%) 226 (7%) 29 (1%) 1,297 (43%) 1,058 (35%) 244 (8%) 238 (8%) 99 (3%) Other: Community Health Centers (CHCs), life insurance companies, health system subsidiaries, publicly traded corporations, health maintenance organizations (HMOs). Other 187 (7%) 195 (7%) 66 (2%) 134 (4%) 74 (2%) *If Partnership, Time to Partner (of 344 searches offering partnership) Immediate One Year Two Years Three Years Four Years Five Years 8 (2%) 152 (44%) 158 (46%) 23 (7%) 0 (0%) 3 (<1%) Note: is the first year this question was asked. 2 Forty-nine States Where Search Assignments Were Conducted AK, AL, AR, AZ, CA, CO, CT, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MN, MS, MT, NC, ND, NE, NH, NJ, NM, NY, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY 5

6 3 Number of Searches by Community Size 0-25, (22%) 730 (26%) 1,281 (39%) 973 (31%) 935 (31%) 25, , (34%) 901 (32%) 1,153 (35%) 851 (27%) 878 (29%) 100,001+ 1,173 (44%) 1,182 (42%) 854 (26%) 1,322 (42%) 1,203 (40%) 4 Top 20 Most Requested Physician Searches by Medical Specialty Family Practice (Includes Family Practice/OB) Internal Medicine Hospitalist Psychiatry Orthopedic Surgery Emergency Medicine OB/GYN Neurology General Surgery Pediatrics Urology Dermatology Hematology/Oncology Gastroenterology Pulmonology Otolaryngology Radiology Cardiology Anesthesiology Endocrinology

7 5 Other Specialty Recruitment Assignments Allergy/Immunology Bone Marrow Transplant Breast Surgery Cardiac Anesthesiology Cardiothoracic Surgery Cardiovascular Surgery Colon & Rectal Surgery Critical Care/Pediatrics Critical Care/Pulmonology CRNA Dentist Dermatology/Pathology Geriatrics Gynecology Gynecology/Oncology Infectious Disease Hepatology Intensivist Internal Medicine /Pediatrics Mammography Maternal/Fetal Medicine Mohs Surgery Musculoskeletal Nephrology Neurohospitalist Neurological Surgery Neurointensivist Neuropsychiatrist Neuroradiology Nocturnist Nuclear Medicine Nurse Practitioner Obstetrics Occupational Medicine Ophthalmology Oral Maxillofacial Surgery Orthopedic Foot & Ankle Surgery Orthopedic Hand Surgery Orthopedic Spine Surgery Orthopedic Total Joint Orthopedic Trauma Pain Management Pathology Pediatric/Anesthesiology Pediatric/Gastroenterology Pediatric/Endocrinology Pediatric/Intensivist Pediatric/Nephrology Pediatric/Otolaryngology Pediatric/Orthopedic Surgery Pediatric/Pulmonology Pediatric/Surgery Physical Therapy Physiatry Physician Assistant Plastic Surgery Podiatry Radiation Oncology Rheumatology Sleep Medicine Surgicalist Surgical Oncology Surgical Pathology Transplant Surgery Trauma Surgery Urological Gynecology Vascular Surgery 7

8 6 Administrative, Academic and Executive Titles Include: Assistant Professor Associate Department Chair Associate Professor Chief Executive Officer Chief Medical Officer Clinical Director Division Chair Department Chair Executive Full Professor Medical Director Residency Director Vice President, Medical Affairs 8

9 7 Income Offered to Top 20 Recruited Specialties (Base salary or income guarantee only, does not include production bonus or benefits) Family Practice Family Practice with Obstetrics $130,000 $178,000 $290,000 $159,000 $197,000 $310,000 $140,000 $175,000 $255,000 $155,000 $320,000 $120,000 $173,000 $245,000 $140,000 $184,000 $275,000 $120,000 $172,000 $275,000 $140,000 $184,000 $275,000 $120,000 $161,000 $145,000 $159,000 Internal Medicine Hospitalist $130,000 $205,000 $285,000 $160,000 $217,000 $305,000 $145,000 $191,000 $165,000 $208,000 $295,000 $140,000 $186,000 $160,000 $201,000 $125,000 $176,000 $330,000 $150,000 $181,000 $135,000 $174,000 $275,000 $145,000 $180,000 Psychiatry Orthopedic Surgery $160,000 $220,000 $275,000 $521,000 $700,000 $150,000 $209,000 $310,000 $519,000 $825,000 $160,000 $481,000 $1,000,000 $120,000 $189,000 $230,000 $439,000 $750,000 $160,000 $186,000 $230,000 $413,000 $650,000 9

10 10 $245,000 $244,000 Dermatology $331,000 $314,000 $297,000 $315,000 $318,000 $500,000 $400,000 $400,000 $400,000 $400,000 $225,000 Hematology/Oncology $369,000 $385,000 $335,000 $365,000 $339,000 $550,000 $500,000 $450,000 $500,000 $500,000 $160,000 $185,000 $185,000 $190,000 $150,000 Emergency Medicine $255,000 $247,000 $244,000 $240,000 $239,000 $380,000 $380,000 $302,000 $258,000 $160,000 $180,000 $180,000 $150,000 $170,000 Neurology $256,000 $281,000 $258,000 $230,000 $234,000 $345,000 $460,000 $375,000 $325,000 $275,000 $120,000 $145,000 $120,000 $120,000 $115,000 Pediatrics $183,000 $180,000 $171,000 $159,000 $159,000 $265,000 $350,000 $265,000 $220,000 $175,000 $150,000 $160,000 OB/GYN $282,000 $272,000 $266,000 $255,000 $247,000 $360,000 $350,000 $655,000 $405,000 $345,000 $205,000 $175,000 $175,000 $240,000 $225,000 General Surgery $336,000 $314,000 $321,000 $321,000 $301,000 $450,000 $410,000 $616,000 $450,000 $350,000 $320,000 $230,000 $275,000 Urology $453,000 $400,000 $401,000 $387,000 $400,000 $550,000 $550,000 $550,000 $550,000 $500,000

11 11 $290,000 $220,000 Anesthesiology $355,000 $331,000 $344,000 $336,000 $475,000 $475,000 $500,000 $480,000 $425,000 Gastroenterology $424,000 $411,000 $393,000 $379,000 $365,000 $505,000 $600,000 $600,000 $475,000 $450,000 $230,000 $230,000 $280,000 $275,000 Otolaryngology $359,000 $349,000 $377,000 $362,000 $312,000 $500,000 $450,000 $450,000 $600,000 $400,000 $270,000 $315,000 $180,000 Cardiology (non-invasive) $420,000 $420,000 $419,000 $392,000 $391,000 $525,000 $600,000 $880,000 $1,000,000 $500,000 $180,000 $180,000 $158,000 $180,000 Endocrinology $218,000 $219,000 $222,000 $205,000 $205,000 $270,000 $270,000 $305,000 $215,000 $225,000 Pulmonology $311,000 $305,000 $293,000 $283,000 $266,000 $430,000 $430,000 $400,000 $525,000 $350,000 $225,000 $225,000 $230,000 Radiology $402,000 $417,000 $391,000 $401,000 $380,000 $450,000 $650,000 $500,000 $750,000 $500,000 $380,000 $325,000 Cardiology (invasive)* $532,000 $495,000 $650,000 $680,000 * is the first year non-invasive and invasive cardiology income offers were listed separately in this survey.

12 8 Type of Incentive Offered Salary Salary with Bonus Income Guarantee Other 428 (16%) 1,975 (74%) 239 (9%) 25 (<1%) 339 (12%) 2,082 (74%) 367 (13%) 25 (<1%) 460 (14%) 2,138 (65%) 526 (16%) 164 (5%) 694 (22%) 1,854 (59%) 598 (19%) N/A 362 (12%) 2,010 (67%) 644 (21%) N/A 9 If Salary Plus Production Bonus, What Type of Bonus was Offered? (of 1,975 searches offering salary plus bonus) Note: 2011 is the first year this question was asked. RVU Based Net Collections Patient Encounters Gross Billings Other 1,026 (52%) 672 (34%) 120 (5%) 21 (<1%) 136 (7%) Other: timely delivery of patient records, qualitative measures, profit share, discretionary bonus, administrative responsibilities, leadership stipend, retention 10 If Income Guarantee, What Type? (of 239 searches offering income guarantees) Net Collections Guarantee Gross Collections Guarantee 231 (97%) 8 (3%) 324 (88%) 43 (12%) 421 (80%) 105 (20%) 500 (84%) 98 (16%) (78%) 143 (22%)

13 11 If Income Guarantee, What was the Term Offered? (of 239 searches offering income guarantees) 1 Year 2 Year 3 Year Other 113 (47%) 77 (32%) 49 (21%) 0 (0%) 202 (55%) 130 (36%) 35 (9%) 0 (0%) 289 (55%) 216 (41%) 0 (0%) 21 (4%) 342 (57%) 198 (33%) 58 (10%) N/A 411 (64%) 200 (31%) 33 (5%) N/A 12 Searches Offering Relocation Allowance Yes 2,451 (92%) 2,671 (95%) 3,222 (98%) 2,896 (92%) 2,954 (98%) No 216 (8%) 142 (5%) 66 (2%) 250 (8%) 62 (2%) 13 Amount of Relocation Allowance High $1,000 $10,454 $85,000 $1,000 $10,035 $30,000 $2,500 $10,427 $25,000 $1,500 $9,807 $20,000 $1,000 $9,808 $75,000 13

14 Signing bonuses, relocation and continuing medical education allowances remain standard in most physician recruitment incentive packages. 14 Searches Offering Signing Bonus Yes No 2,025 (76%) 2,135 (76%) 2,795 (85%) 2,326 (74%) 2,173 (72%) 642 (24%) 678 (24%) 493 (15%) 820 (26%) 843 (28%) 15 Amount of Signing Bonus Offered (of 2,025 searches offering signing bonus) High $5,000 $23,790 $2,000 $22,915 $100,000 $5,000 $24,850 $75,000 $4,000 $24,800 $5,000 $20,000 $100, Searches Offering Continuing Medical Education Yes No 2,559 (96%) 108 (4%) 2,618 (93%) 195 (7%) 3,158 (96%) 130 (4%) 2,863 (91%) 283 (9%) 14 2,746 (91%) 270 (9%)

15 17 Amount of CME Pay Offered (of 2,559 searches offering to pay CME) High $500 $3,194 $10,000 $500 $3,335 $15,000 $1,000 $3,121 $6,500 $700 $3,924 $35,000 $1,000 $3,312 $15, Searches Offering to Pay Additional Benefits 2005/06 Health Insurance 99% 98% 91% 95% 91% 91% Malpractice 97% 99% 94% 96% 91% 92% Retirement 90% 90% 85% 91% 72% 70% Disability 77% 84% 75% 79% 69% 70% Educational Loan Forgiveness 29% 38% 31% 35% 26% 34% Housing Allowance 6% N/A N/A N/A N/A N/A Other 3% N/A N/A N/A N/A N/A 19 If Educational Loan Forgiveness was Offered, What was the Term? (of 772 searches offering educational loan forgiveness) One Year 39 (5%) Two Year Three Year 208 (27%) 525 (68% Note: is the first year this question was asked. 15

16 TRENDS AND OBSERVATIONS Merritt Hawkins annual Review of Physician Recruiting Incentives, now in its 18th year, tracks three key physician recruiting trends First, based on the physician recruiting assignments Merritt Hawkins is contracted to conduct, the Review indicates which types of physicians are in the greatest demand and which are the most challenging to recruit. Second, the Review indicates what types of communities are recruiting physicians based on population size and the types of practice settings into which physicians are being recruited. Third, the Review indicates the types of financial and other incentives that are being used to recruit physicians. Each of these trends is discussed below WHO IS IN DEMAND? Merritt Hawkins 2011 Review of Physician Recruiting Incentives examines the permanent physician recruiting assignments Merritt Hawkins/AMN Healthcare s physician staffing companies were engaged to conduct during the 12 month period from April 1, 2010 to March 31, These search assignments reflect which types of physicians hospitals, medical groups, and other organizations are seeking nationwide. They also reflect which types of physicians may be particularly difficult to recruit, necessitating the assistance and additional resources of a physician recruiting firm. Economic Factors During the 12-month period covered by the Review, the economy saw only modest growth in healthcare related employment, a trend generally reflected in the physician recruiting market. Beginning in 2008, a decrease in utilization of some medical services (particularly elective procedures), tight capital markets, reimbursement cuts, and the uncertainty engendered by healthcare reform, caused many hospitals, medical groups and other healthcare organizations to remain relatively cautious in regard to physician recruiting, delaying or scaling back their staffing plans. In recent months, however, there have been signs that utilization (including elective procedures) may be increasing, as reflected by renewed search activity for specialists who commonly perform electives, such as orthopedic surgeons, dermatologists, and general surgeons. 16 The sluggish economy also has affected the willingness and/or the ability of some physician candidates to relocate. Given the financial climate, some physicians have chosen to ride out the economic recovery where they are rather than embracing new opportunities, while others are restricted in their ability to move because of unfavorable real estate positions. Some older physicians, their financial portfolios downgraded by the recession, have chosen to postpone retirement, obviating the need to recruit to replace them.

17 The economics of healthcare and the passage of Patient Protection and Affordable Care Act ( health reform ) also shaped the physician recruiting market in the last 12 months. In order to achieve physician integration and alignment, and so benefit from emerging cost and quality based reimbursement methods, many health systems and medical groups have acquired or merged with physician practices. Acquisitions and integration to some extent replaced traditional recruitment in the last year, as healthcare organizations have focused on preparing for new delivery models. As this trend plays out, there has been a nationwide lull in the traditional physician recruiting market, which is only now showing signs of returning to its customary vigor. Primary Care Boom Continues In cases where health facilities have proceeded with physician recruiting, the strongest area of demand remains primary care, defined in this Review as family medicine, general internal medicine, and pediatrics. For the fifth consecutive year, family medicine was Merritt Hawkins most requested search assignment, with general internal medicine second (also for the fifth consecutive year). In the last several years, pediatrics has risen up the list of Merritt Hawkins most requested search assignments and was the tenth most requested assignment this year (by contrast, in 2005/06 pediatrics was not in the top 20). Primary care physicians have become a particular focus of recruiting efforts for several reasons. In the 1990s, many medical school graduates gravitated toward primary care residencies, enhancing supply, while today medical graduates are largely avoiding primary care (this is particularly true of U.S. medical graduates). Many residency programs, particularly in family medicine, fall well short of filling their available positions. The chart below illustrates this trend: Declining Interest In Primary Care Total Medical Students Matched to Residency Programs, 2010 # planning careers in primary care Percent of all doctors in primary care, 1950 Percent of all doctors in primary care, 2011 *Source: New York Times, June 23rd, ,378 3,891-4,385 (16% - 18%) 50% 35% 17

18 This contraction in supply coincides with the renewed focus that hospitals and medical groups are putting on primary care after several years of neglect in the early part of this decade. In the case of internal medicine, population aging is driving demand. General internists often manage the care of middle-aged to elderly patients, the fastest growing population segment. These patients often have multiple chronic illnesses and typically visit a physician at three times the annual rate of younger patients. The current number of general internists being trained is insufficient to meet the demand generated by an aging population, while many internists are choosing to practice as hospitalists, further inhibiting supply. Practice style and physician demographics are additional factors inhibiting supply. Many physicians are embracing part-time practice or are seeking structured hours as part of a controllable lifestyle. Female physicians, who typically work fewer hours than male doctors, are concentrated in primary care, eroding the total number of primary care full-time equivalents (FTEs). General population growth also is a factor. The U.S. Census Bureau indicates the nation s population will grow by 49 million people from 2000 to 2020, as the chart below indicates: U.S. Population in Millions *Source: US Census Bureau This growth will be generated by new births and by an influx of immigrants, most of whom are comparatively young and require the services of both family physicians and pediatricians. The number of physicians being trained in the U.S., meanwhile, has remained virtually static for over 20 years. Health reform, which encourages the use of value and cost-based physician and hospital reimbursement, also is promoting demand for primary care. Through the medical home and electronic medical records application, primary care physicians are seen as key to implementing quality and cost-based metrics. The Patient Protection and Affordable Care Act included provisions intended to increase the supply of primary care physicians, in part by redistributing residency positions from hospitals where they are not being used to hospitals where they will be used. However, this will only increase the number of physicians completing training by several hundred a year, whereas thousands more per year are required to address projected physician shortages. A detailed discussion of how health reform will affect physician supply and demand is included in Health Reform and the Decline of Physician Private Practice, a white paper Merritt Hawkins completed on behalf of The Physicians Foundation, a non-profit grant-making organization (see Hospitalists, Psychiatrists in Demand 18 Demand also remains robust for hospitalists who provide inpatient care in a hospital setting. Hospitalist physicians, who are largely comprised of general internal medicine practitioners, were Merritt Hawkins third most requested search assignment in. Hospitalists have been among Merritt Hawkins top four requested specialties for five consecutive years. Hospitalists are proving a popular and effective way of enhancing quality of care, reducing medical errors and managing costs. In addition, by relieving office-

19 based physicians of inpatient work, hospitalists can increase medical staff retention and satisfaction rates. However, because so many internal medicine practitioners are choosing to practice as hospitalists, largely to enjoy the lifestyle benefits of defined shifts, the supply of general internists has become constrained, making internal medicine one of the most difficult search assignments to fill today. The 2011 Review confirms the continued steep increase in demand for psychiatrists, a specialty where supply is increasingly unable to keep up with demand. Seventy percent of psychiatrists are 50 years old or older and many are at or near retirement age, as the chart below indicates: Psychiatrists by Age 40 or younger or older All active physicians 50 or older 10% 20% 31% 39% 43% Psychiatry is attracting fewer medical school graduates, particularly American-trained graduates, as more than 30 percent of active psychiatrists are international medical graduates (IMGs). Many psychiatrists today are seeking outpatient practice settings, so that it is increasingly difficult for inpatient facilities to recruit the physicians they need. Meanwhile, the incidence of behavioral health problems in the United States continues to increase, with the Bureau of Health Professions projecting that demand for general psychiatry services will increase 19 percent between 1995 and 2020, while demand for child and adolescent psychiatric services will increase 100 percent in the same timeframe. Psychiatric problems related to stress are particularly prevalent during periods of unemployment and slow economic growth such as we are currently experiencing. Consequently, the number of psychiatry search assignments Merritt Hawkins conducts increased for six consecutive years, and was the firm s third most requested search in. Though psychiatry slipped to Merritt Hawkins fourth most requested search in, demand for the specialty remains strong. The 2011 Review also indicates that demand persists for various types of specialists, including emergency medicine physicians, obstetrician/gynecologists, general surgeons, urologists, and dermatologists. The 2011 Review confirms the continued steep increase in demand for psychiatrists, a specialty where supply is increasingly unable to keep up with demand. Seventy percent of psychiatrists are 50 years old or older and many are at or near retirement age. 19

20 Market Soft for Radiologists, Anesthesiologists, Cardiologists Demand for certain specialists -- radiologists, cardiologists, and anesthesiologists in particular -- has been inhibited by the economy and by changes to provider reimbursement. Each of these specialties was formerly among Merritt Hawkins top five recruiting assignments six or seven years ago. Today, they rank 17th, 18th and 19th respectively (see chart below): 2004/05 number of Merritt Hawkins Search Assignments: Radiology, Cardiology, Anesthesiology 2010/2011 vs. 2004/05 Radiology Cardiology Anesthesiology A decrease in both elective procedures and non-elective procedures has eroded demand for anesthesiologists at a time when many medical school graduates are choosing to specialize in anesthesiology. In addition, certified registered nurse anesthetists (CRNAs) often are used in lieu of anesthesiologists or as a supplement to the anesthesiologist staff. Medicare reimbursement cuts to radiologists, decreased utilization of some imaging procedures, and continued interest in radiology among medical graduates have helped to balance out the demand for radiologists and available supply. Cardiologists have been particularly hurt by reduction in Medicare reimbursement for various cardiology procedures and by treatment protocols that now favor drugs over certain types of surgical procedures. While demand for physicians in various specialties tends to run in cycles, the general trend in physician recruiting today is characterized by a continued demand for physicians in primary care and in a number of hospital-based and surgical specialties. The ability of many health facilities to recruit the physicians they need has been inhibited by the recession, but recruiting activity can be expected to increase as the economic climate improves and the move toward acquisitions and integration slows. 20 In addition, in the next several years, the new health reform law is likely to provide insurance to over 30 million patients who now lack medical coverage. Many of these patients will be seen at Community Health Centers (CHCs) which are assuming a larger role in providing care for traditionally underserved populations. This influx of newly insured patients can be expected to increase demand for physicians in multiple specialties nationwide.

21 WHERE ARE THEY RECRUITING? INTO WHICH SETTINGS? The 2011 Review confirms another physician recruiting pattern that has become apparent over the last several years: an increasing number of hospitals are employing physicians. Direct employment of physicians by hospitals was one hallmark of managed care in the 1990s, but the practice was largely dropped as hospitals found the physician employment model problematic. The 2011 Review shows that 56 percent of Merritt Hawkins physician search assignments were for settings featuring hospital employment of the physician, up from 51 percent the previous year and up from 23 percent in 2005/06. The following graph shows Merritt Hawkins search assignments that featured settings in which the hospital is employing the physician. Hospital-Based search assigments (11%) 510 (19%) 654 (23%) 1,495 (56%) 1,430 (51%) 1,579 (45%) 1,416 (45%) 1,297 (43%) 21

22 The current trend toward hospital employment of physicians is different from the 1990s, when hospitals typically approached physicians about employment opportunities rather than the reverse. Today, many physicians, specialists in particular, are seeking hospital employment to relieve them of the stress of malpractice rates, the struggle for reimbursement, administrative duties and the general risks and hassles of private practice (a detailed examination of this trend is included in the white paper Health Reform and the Decline of Physician Private Practice referenced above). Hospital employment is viewed favorably by many physicians today and hospitals offering employed positions generally enjoy an advantage over those that do not. In addition, health reform promotes the use of Accountable Care Organizations (ACOs), which will depend on close physician/hospital cooperation to improve quality of care and reduce costs. Physician employment by the hospital is one way to achieve the strategic, financial, and information technology alignment between physicians and hospitals that is needed to implement the ACO model and the trend toward hospital employment of doctors can therefore be expected to continue. The 2011 Review indicates that Merritt Hawkins represented physician search assignments in 49 states (all states except Delaware) during the 12-month period from April 1, 2010 to March 31, Hospitals, medical groups and other organizations in almost every state found it necessary or desirable to retain the services of a physician search firm such as Merritt Hawkins, suggesting that physician recruiting challenges still exist nationwide, even in a recovering economy. Moreover, 44 percent of Merritt Hawkins search assignments took place in communities of 100,000 people or more, while 22 percent took place in communities of 25,000 people or fewer. It is no longer communities in traditionally underserved rural communities that find it challenging to recruit physicians. Due to a general physician shortage, particularly in primary care, medical organizations in communities of all sizes now may at times require the services of physician search firms. 22

23 WHAT ARE THEY OFFERING? The 2011 Review indicates that continued demand for family physicians, internists and pediatricians is having an upward trending effect on financial incentives. salaries or income guarantees offered to family physicians increased from $161,000 in to $178,000 in (an 11 percent increase), while average salaries or income guarantees offered to general internists increased from $174,000 in to $205,000 in (an 18 percent increase). income offers for pediatricians also have seen gains, from $159,000 in to $183,000 in (a 15 percent increase). Though many healthcare facilities scaled back their recruiting efforts during the recession and slow recovery, they nevertheless found it necessary to increase income offers to physicians in certain specialties that remain in relatively demand and are still difficult to recruit, including both primary care and some specialty areas. Increased salaries also can be a result of hospital efforts to attract physicians to employed settings. The 2011 Review indicates that some average income offers increased for specialists such as orthopedic surgeons, hospitalists, obstetrician/gynecologists, psychiatrists, emergency medicine, pulmonologists, gastroenterologists, and dermatologists. Specialties Showing Highest Gain in Income Offers from 2009/ /2011 % Increase Urology $400,000 $453,000 13% Internal Medicine $191,000 $205,000 7% General Surgery $314,000 $336,000 7% Invasive Cardiology $495,000 $532,000 7% Anesthesia $331,000 $355,000 7% Volume/Production Trumps Qualitative/Cost Incentives Reflecting the growing number of employed physicians, most income packages offered to physicians today are structured as salaries or salaries with production bonuses. Income guarantees, which typically are offered to independent, private practice physicians, have become progressively less utilized in recent years. Ninety percent of the physician search assignments Merritt Hawkins conducted in offered either straight salaries or salaries with production bonuses, while only nine percent offered private practice income guarantees. Seventy-four percent of all search assignments offered a salary with some type of production bonus. Of these, the majority (52 percent) featured a production bonus calculated on Relative Value Units (RVUs). RVUs are a metric for determining physician productivity based on work units performed by a physician, rather than number of patients seen. For example, a physician may be assigned a larger number of RVUs for examining a patient with acute diabetes than for examining a patient with a cold. 23

24 Additional production bonus formulas were calculated on other volume based metrics such as net or gross physician collections or on number of patients seen. Very few of Merritt Hawkins search assignments featured physician bonuses that reward physicians for improving quality or decreasing costs, despite the prevailing rhetoric regarding value-based compensation. Though health reform and market forces are driving the market toward quality and cost based physician reimbursement, rather than volume or production based, Merritt Hawkins 2011 Review indicates that in the real world production and volume continues to trump quality and cost in calculating physician compensation. Signing Bonuses and Housing Allowances Current and past Reviews indicate that the number of hospitals, medical groups and other organizations offering physician signing bonuses has steadily increased over the last 10 years. In the 1990s, searches offering signing bonuses were the exception; the 2011 Review indicates that they are now generally the rule. Signing bonuses were offered in 76 percent of the recruiting assignments Merritt Hawkins conducted in, a number that has remained relatively consistent over the last several years. In general, signing bonuses are now expected by candidates as a way to address the rising costs of practice relocation. The following graph illustrates the use of signing bonuses over the last several years. searches offering signing bonuses 85% 72% 74% 76% 76% 58% 46% 2004/ /06 24 Signing bonuses offered in averaged $23,790, up marginally from $22,915 the previous year.

25 Certain other incentives, such as paid relocation, paid CME, health insurance and malpractice insurance are standard in the majority of Merritt Hawkins physician search assignments. The average relocation allowance offered in was $10,454, up slightly from $10,035 the previous year, while the average CME allowance in was $3,194, down marginally from $3,335 the previous year. In addition, 29 percent of Merritt Hawkins search assignments featured medical education loan forgiveness, down from 38 percent the previous year. Educational loan forgiveness entails payment by the recruiting hospital or other facility of the physician s medical school loans in exchange for a commitment to stay in the community for a given period of time. The term of forgiveness in the majority of searches Merritt Hawkins conducted in (68 percent) was three years; 27 percent of searches offered a twoyear term, and five percent offered a one year term. The 2011 Review tracks a new physician recruiting incentive: housing allowances. Given the current volatile real estate market, some physician candidates are unable to leave their current homes in order to relocate. Housing allowances help pay for their housing in their new location, allowing them the flexibility to relocate. Such allowances were offered in six percent of the search assignments Merritt Hawkins conducted in, up from less than one percent prior to the economic downturn. 25

26 SUMMARY Merritt Hawkins 2011 Review of Physician Recruiting Incentives underscores the fact that the slow economic recovery has had an inhibiting effect on physician recruiting activity at many hospitals, medical groups and other healthcare organizations. In addition, traditional physician recruiting in the last 12 months was in some cases supplemented or replaced by physician practice acquisitions or mergers. Nevertheless, competition for physicians in certain specialties remains intense, causing average income offers to increase year over year. Demand for primary care physicians remains particularly strong, as they are seen as the keys to achieving quality and cost objectives necessary under new delivery models such as Accountable Care Organizations (ACOs). Hospital employment of physicians also is increasing as many physicians seek the security and relative simplicity of an employed position and as many hospitals seek to form ACOs and other physician-aligned models. However, though physician compensation is moving toward cost and quality metrics, the 2011 Review indicates that volume/production remains the standard method for incentivizing doctors. The 2011 Review suggests that recruiting physicians remains a national challenge, as Merritt Hawkins conducted search assignments in 49 states in. This challenge is not confined to traditionally underserved rural areas but is prevalent in communities of all sizes. Health reform, which is projected to add millions of insured patients to the mix, is likely to exacerbate these trends. 26

27 Merritt Hawkins Additional Surveys Merritt Hawkins is an AMN Healthcare company. AMN Healthcare is the largest healthcare staffing organization in the United States. Other surveys conducted by Merritt Hawkins or other AMN companies include: Physician and Health Reform Medical Practice: The Physicians Perspective Survey of Physicians 50 to 65 Years Old Physician Inpatient/Outpatient Revenue Survey Survey of Final Year Medical Residents Survey of Primary Care Physicians Review of Temporary Healthcare Staffing Trends & Incentives Review of Temporary Healthcare Staffing Trends & Incentives (Mid-level Providers) Survey of Chief Nursing Officers Survey of Men in Nursing Survey of Travel Nurses Survey of Nurse Students Books Written by Merritt Hawkins: Will the Last Physician in America Please Turn Off the Lights? A Look at America s Looming Physician Shortage, Fourth Edition 2008 Merritt Hawkins Merritt Hawkins Guide to Physician Recruiting, Third Edition 2009 Merritt Hawkins In Their Own Words: 12,000 Physicians Reveal Their Thoughts on Medical Practice in America The Physicians Foundation To order these books from the publisher, visit: or, for In Their Own Words, For additional information about this survey or other information generated by Merritt Hawkins or AMN Healthcare, please contact: Merritt Hawkins / Corporate 5001 Statesman Dr Irving, Texas (800) Merritt Hawkins / Atlanta 7000 Central Parkway, NE Suite 850 Atlanta, GA (800) Merritt Hawkins / Irvine Von Karman Ave Suite 400 Irvine, CA (800) MerrittHawkins.com 2011 Merritt Hawkins 27

28 SPEAKING PRESENTATIONS FROM MERRITT HAWKINS AND AMN HEALTHCARE Merritt Hawkins and AMN Healthcare are committed to providing survey data and other information of use to healthcare executives, physicians, policy makers and members of the media. AMN Healthcare offers speakers to address healthcare industry trends in staffing, recruiting and finance. Topics include: * Evolving Physician Staffing Models * Physician and Nurse Shortage Issues and Trends * New Strategies for Healthcare Staffing * Healthcare Reform and Workforce Issues * Economic Forecasting for Clinical Staffing * Allied Staffing Shortages * Vendor Management * Recruitment Process Outsourcing * Other topics Upon Request Our speakers have a combined six decades of staffing experience. Each speaker offers a unique perspective to educate your audience and provide new insights into the trends and future of healthcare staffing. For more information or to schedule a speaking engagement, please contact: Phillip Miller (800)

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